Appointment Request Form
Today's Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Legal Name:
*
First Name
Last Name
Client Date of Birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex:
*
Parent/Legal Guardians Name (If Applicable):
First Name
Last Name
Mailing Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Phone Number:
*
Format: (000) 000-0000.
Email
*
example@example.com
Are you able to receive texts at the phone number provided?
*
YES
NO
How were you referred to our office?
*
Previous Client
Insurance Company
Primary Care Provider
Employee Assistance Program
Child Protective Services
Attorney
Family/Friend
Other
Primary Care Provider:
Please select the appropriate reason for referral. In the section below, please provide greater detail.
*
Counseling
Psychological or Neuropsychological Testing
Please provide a brief reason for coming in below. This assists us in setting you up with a clinician that will meet your needs.
Do you have a provider in mind? If not, please list whether you prefer a male or female therapist or no preference.
In the past year have you thought of harming yourself or others?
*
YES
NO
If yes, and this is an urgent issue. You may reach out to the 24/7 crisis line by calling 360-425-6064 or texting 988 or calling 911 if this is an emergency.
If this is an emergency, please do not wait for our office to contact you, seek help immediately.
Insurance Information
If you are utilizing your insurance benefits, the section below is required.
Insurance Company Name:
Subscriber ID #:
Group #:
Customer Service Phone #:
Subscriber's Name:
First Name
Last Name
Subscriber's Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Subscriber's Employer:
Please upload an image of the front & back of your insurance card(s):
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Secondary Insurance Information
If applicable, please complete secondary insurance information. This section is required if you intend to use secondary insurance benefits.
Secondary Insurance Company Name:
Secondary Subscriber ID#:
Secondary Group #:
Customer Service Phone Number:
Secondary Insurance Subscribers Name:
First Name
Last Name
Secondary Insurance Subscriber's Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Secondary Insurance Subscriber's Employer:
Submit
Office Use Only
Should be Empty: